TORONTO -- Dr. Marko Duic has been celebrated by health ministry officials, hospital leaders and doctors for transforming emergency medicine. He's been hailed as an expert at reducing waiting times. Other hospitals have invited him to help them implement his care model in their emergency wards.

But over his 16 years as an emergency chief, another truth about Dr. Duic has emerged: He had not hired a single female doctor to work in his departments until October, weeks after The Globe and Mail began asking questions about his hiring practices. And hospital administrators had previously allowed those practices to go unchecked, a Globe and Mail investigation reveals.

Over the past five months, The Globe has spoken to 18 physicians who worked under Dr. Duic. Another eight were aware of concerns about his leadership. Most spoke anonymously, some because they were concerned that Dr. Duic had powerful connections in emergency medicine and that speaking publicly about him could lead to negative career repercussions for them.

Others worried that they might get fired or passed over for a promotion for talking to the media about their current or past workplaces.

Nearly all of the doctors said Dr. Duic is infamous for only hiring men. Some also raised concerns about his billing practices, alleging Dr. Duic encouraged his staff to sign forms recommending driver's licences be taken away from patients, even when the measure wasn't warranted, as a way to boost billings.

The Globe began examining Dr. Duic's track record in June.

In early 2018, a physician had posted concerns about his hiring practices in a closed Facebook group for female doctors.

The post attracted a flurry of comments and was taken down, but a group of eight physicians decided to keep talking. They were frustrated no action had been taken during his long reign as emergency chief, first at St. Joseph's Health Centre in Toronto, and now at Southlake Regional Health Centre, north of the city.

The women conducted a survey of the gender breakdowns in 28 similarly sized emergency departments, most of them in Ontario. The results showed that Southlake, where Dr. Duic has been ED chief since 2011, was an outlier. On average, the gender breakdown was 34-per-cent female, with female physicians in each department ranging from 13 per cent to 63 per cent. Southlake's ED, which includes more than 30 doctors, was the only department without a single female physician at the time.

The group decided to hire a lawyer, Toronto-based Danny Kastner, and to launch a formal complaint. In March, Mr. Kastner sent a letter on behalf of the group of women, who chose to remain anonymous because they were worried about possible repercussions to their careers.

The group of eight includes four emergency physicians and four doctors from other specialties; all are based in Ontario.

Some of them have had negative encounters with Dr. Duic; others have heard about his hiring practices from colleagues.

The letter called on Southlake and the University of Toronto, which sends trainees to the hospital, to launch an independent investigation to examine alleged gender discrimination in both the hiring and training of doctors, and to remove Dr. Duic from hiring and teaching roles in the meantime. Both institutions wrote back to Mr. Kastner and explained they conducted internal investigations and did not find solid evidence of discrimination.

In October, The Globe sent a list of questions to Southlake CEO Arden Krystal and chief of staff Dr. Steven Beatty regarding the doctors' concerns about gender discrimination and allegations of questionable billing practices. In a written response, Kathryn Perrier, strategic communications consultant for Southlake, said that while the hospital didn't find any evidence of gender discrimination in its internal investigation in the spring, an independent investigation has been ordered "in light of the new information [The Globe has] provided." Later that month, the hospital hired a female emergency doctor, Dr. Catherine Grenier. Ms. Perrier did not comment on the billing concerns, saying that was a matter between physicians and the Ministry of Health.

The Globe also sent questions detailing all allegations described in this article to Dr. Duic.

He did not respond to the sixpage letter from The Globe.

Setareh Ziai, president of the Canadian Women in Medicine, is encouraged that Southlake has asked an independent investigator to review the issue.

"For years, our members have heard allegations of gender discrimination involving Dr. Marko Duic," she said. "We are united in the belief that there is no place for discrimination in our learning, teaching or practising environments."

Duic arrived, and they stayed that way under him. When he took over as chief at St. Joseph's in 2002 and then at Southlake in 2011, the hospitals had "fixed" shifts. For the most part, shifts would start and end at the same time. Dr. Duic introduced a "floating" schedule, one where doctors would frequently be called in early if the emergency department was busy, and might be asked to stay later. He pushed doctors to check patient vitals in waiting rooms, to speed services along.

The model was credited with transforming emergency medicine at both St. Joseph's and Southlake, bringing them from near the bottom of the list in waiting-time performance, to the top.

But reports from St. Joe's and Southlake show that since 2002, Dr. Duic hired, at a minimum, 23 male doctors, and zero female doctors.

Dr. Alecs Chochinov, current president of the Canadian Association of Emergency Physicians, told The Globe that "it would be a statistical improbability that in this day in age there would be no women on any staff of 30, because Canada produces a lot of female emergency doctors."

According to data from the Canadian Resident Matching Service, since 2007, on average, 97 women have specialized in emergency medicine for every 100 men.

Southlake Regional Health Centre is located in Newmarket, Ont., a growing suburb north of Toronto. Southlake's emergency department was built to provide care for 70,000 patients a year, but in 2018, more than 111,000 poured into the emergency department. Dr. Duic had been brought in to address the crunch.

In his complaint letter sent to Southlake and the University of Toronto this spring, Mr. Kastner alleged it appeared that Dr. Duic not only refuses to hire women, but also to train them. The letter included several anonymous accounts from female doctors who trained with Dr. Duic or applied to his department. These accounts were based on interviews the complainants had conducted.

The Globe spoke with one of the eight complainants to whom it granted anonymity; the others would not speak to a journalist out of concerns doing so would harm their careers. The Globe also obtained the four-page letter their lawyer sent to Southlake and the university, along with the responses sent by both institutions.

"There is a culture of fear," Mr.Kastner said. "My clients have heard many times about reprisals against doctors who pushed back against his agenda."

Dr. Beatty, chief of staff at Southlake, wrote back to Mr.Kastner in April, a month after the complaint was sent. Dr. Beatty said Dr. Duic had encouraged several female physicians to apply to the department, and according to Dr. Duic, they declined.

"The only evidence that Southlake has engaged in discriminating practices is the absence of female emergency physicians currently providing care in the emergency department at Southlake," Dr. Beatty wrote. "In 2018, we should not be talking about 'gender' as a two-sided coin alone. In fact, the current 'diversity' in our emergency department is very much aligned with current societal norms, with representation from individuals of varying sexual orientation, race and age."

However, Dr. Beatty attached data that appeared to reinforce the complainants' concerns. An analysis of the data shows that from April, 2011, to April, 2015, Dr.Duic supervised 25 male trainees and no females. During that time, 35 female and 66 male trainees rotated through the hospital.

"My clients were disappointed and, frankly, disturbed by the response," Mr. Kastner said in an interview. "Both institutions seemed to send the message: We don't want to hear about it."

Dr. Steve Flindall and Dr. Jason Falk were on staff at Southlake when Dr. Duic took over. Both said they didn't see Dr. Duic scheduled to work with female

residents, and he usually had multiple male residents working with him. "He would choose the residents he wanted to mentor," Dr. Flindall said.

Occasionally, Dr. Duic was scheduled with a female resident at St. Joseph's. The Globe spoke to four women who worked with Dr. Duic on training rotations, and all described his attitude as dismissive.

In 2013, Dr. Eileen Cheung, now an emergency physician in Toronto, was a resident at St. Joseph's. On one shift, Dr. Cheung found herself scheduled with Dr.

Duic. She recalled that he made her feel like she was too slow, and that she was interrupting him by asking questions.

"He seemed very annoyed that I would approach him for any clinical question even though, medically and legally, he was responsible for the patients I saw."

One doctor who worked closely with Dr. Duic said he heard him say that a female emergency doctor "didn't have the right chromosome."

Another former resident said that at the end of her shift, Dr.Duic said to her, "It's too bad you're a good resident because you will have children and your training will be a waste." The doctor, who now works in an emergency department in Toronto, said she subsequently told the doctor in charge of residents at the time. She had hoped there would be some sort of action, a formal report or a reprimand. Instead, she said the doctor she reported to simply apologized to her, and told her it was unfortunate the physician who should have been supervising her had been ill.

In February, 2011, a female resident at St. Joe's wrote Dr. Duic to inquire about job opportunities.

She provided The Globe with what she said was his e-mailed response: "Unfortunately, we have quite a queue of great EPs [emergency physicians] who aspire to work with us, and wish we could give them all positions," he wrote. "It will be a number of years before we can think of offering anyone else a position, but you're welcome to check again in 6-8 years."

Dr. Duic's tenure as chief was ending in 2012. He was essentially telling the applicant that not only he, but whoever superseded him, wouldn't consider her for at least six years. Four doctors who work at St. Joseph's said Dr. Duic had for a time influenced the hiring decisions of subsequent chiefs.

But in the past three years, St.Joe's emergency department has gone from having no women to 13; women now make up about a third of the emergency doctors.

Why did Dr. Duic care about influencing St. Joe's hiring after he moved on as chief? According to three physicians at St. Joe's, Dr.

Duic wants to be able to hold job possibilities over young, male physicians. And jobs at St. Joe's, in Toronto, are more desired than jobs at Southlake, in Newmarket. "He likes to deliver and he treats people he likes really well," one doctor said. One perk of Dr. Duic's esteem: an invite to exclusive opera performances at his Forest Hill home.

The Globe sent a list of questions to Dr. Tim Rutledge, current CEO of St. Joseph's Health Centre.

He did not respond to the questions. Instead, Michael Oliveira, a media spokesperson, provided a statement attributed to St. Joseph's that read, in part: "You have raised a number of troubling issues from previous years.

These are not active issues in our Emergency Department."

He added: "Any discrimination in hiring practices based on gender, race or cultural background is unacceptable in our organization. Since 2016, gender balance in the Emergency Department has changed significantly to include diverse backgrounds and experiences. ... This includes a balance in female physicians in the department."

Mr. Oliveira said Dr. Duic still has privileges at the St. Joseph's emergency department, meaning the department has not revoked his right to work there. Mr.

Oliveira noted that billing by physicians is not managed by the hospital.

BILLING PRACTICE CONCERNS Within the first week that The Globe was interviewing physicians about Dr. Duic, doctors raised concerns about his billing practices.

Doctors who have worked with Dr. Duic described methods they said he used and encouraged to increase billings at St.

Joe's and Southlake. Five doctors who worked with him alleged that Dr. Duic encouraged the overuse of Ministry of Transportation forms on patients, which would earn doctors more money.

Four doctors alleged that under Dr. Duic's leadership at St.

Joesph's, physicians overused psychiatric forms that were used to keep patients involuntarily in the hospital longer. And one former Southlake doctor recalled an emergency department talk on how to boost billings at which Dr.

Duic told physicians they should increase their use of psychiatric forms, also known as Form 1s.

"Emergency medicine was never particularly attractive financially, and certainly not for the hours," said Dr. Falk, who worked with Dr. Duic at Southlake. "Young people find it interesting and exciting, but as they get older often want to get out.

Dr. Duic was unusual in that he found a way to monetize it."

Ministry of Transportation forms are filled out by doctors when they're concerned about a patient's fitness to drive. They often result in a temporary or permanent licence revocation. Physicians remunerated on a fee-forservice basis are paid $35 a form.

Someone who has had an unexplained seizure shouldn't be behind the wheel, but physicians said Dr. Duic would also fill out the form for patients who were in nursing homes or were severely disabled and wouldn't have had a licence to begin with.

Several doctors said patients were complaining to both hospitals that their licences had been taken away unjustly and, in many cases, patients weren't aware the emergency doctor was concerned about their driving until they got a notice in the mail that their licences had been revoked.

A doctor who works at St. Joe's added the hospital's medical advisory committee was concerned about the inappropriate use of transportation forms, because of patient complaints.

Through a Freedom of Information request, The Globe accessed redacted minutes of a 2011 meeting of that committee.

"There has been a definite improvement in the number of MTO forms being done. However, there were still concerns regarding appropriate documentation and patient/family notification.

Dr. Duic will follow up with the physicians in the ED," the minutes read.

Emergency specialists Dr. Falk and Dr. Kashif Pirzada both worked at Southlake when Dr.

Duic took over as chief in 2011, and later left because of disagreements with him. They both noticed the seemingly inappropriate use of MTO forms after Dr.

Duic took over as chief.

"The use of MTO forms increased dramatically as an initiative of Marko's and it was source of friction with patients and the hospital was aware," Dr. Falk said.

Dr. Pirzada said he brought up his concerns about MTO form use in department meetings.

In 2013, Dr. Duic sent an e-mail to more than 30 emergency doctors, which was forwarded to The Globe by one of the recipients. In the e-mail, Dr. Duic demanded that doctors fax their own MTO forms so that other hospital staff don't see them. He explained that, otherwise, administrative staff at the hospital might ask "why a nursing home patient with flexn contractures got MTO'd."

According to a number of doctors interviewed, there would be no need to fill out a form for a nursing home patient with flexion contractures (caused by being immobile in bed for weeks) because that person wouldn't be driving anyway.

At St. Joseph's emergency department, there were 2,902 MTO forms filled out from April to December of 2011, a time when Dr.

Duic was the hospital's emergency chief. In comparison, 214 such forms were filled out in 2017.

Ministry of Health data, accessed through Freedom of Information requests, show there were 1,126 MTO forms filled out at Southlake emergency in 2012, higher than all six Greater Toronto Area hospitals used as comparison, and many times higher than four of those. The number of forms filled out in the Southlake emergency began to drop in 2013, and by 2016, it was down to 452. Southlake did not respond to The Globe's inquiry as to whether the hospital was aware of the high use of MTO forms, and whether administrators intervened.

The Globe also heard concerns about the use of psychiatric forms. Doctors fill out Form 1s when they deem a patient is at risk to themselves or others because of psychiatric symptoms.

The form commits patients in the hospital involuntarily for up to 72 hours. Physicians paid on a fee-for-service basis get $105 every time they fill one out.

Ministry data show Form 1s were used more frequently at Southlake in 2016 than at three other comparison hospitals, but less frequently than at a fourth, Brampton Civic.

At St. Joe's, emergency physicians filled out Form 1s on 1,298 patients from April to December of 2011, the earliest year for which ministry data are available. Dr.

Duic was chief of St. Joe's emergency department until 2012, according to Mr. Oliveira, and continued to work shifts in the department after he moved to his new role as chief at Southlake.

The Globe accessed data for four comparison Greater Toronto Area hospitals for the same time period. The number of times doctors in these hospitals filled out Form 1s in 2011 ranged from 341 to 509.

While St. Joe's emergency sees more psychiatric patients than most Ontario hospitals, the use of Form 1s dropped to 735 in 2017.

Meanwhile, Form 1s increased at all of the other comparison hospitals.

The Globe asked St. Joseph's CEO Dr. Rutledge whether the administration was aware of the billing issues. He did not respond, but a statement from the hospital said billing by physicians is not managed by the hospital.

The Globe also asked Ministry of Health spokesperson David Jensen whether the ministry knew of the disproportionately high rates of MTO forms and Form 1s at the two hospitals in previous years, and whether the ministry planned to take any action. Mr. Jensen responded: "The ministry takes all reports of inappropriate billings to OHIP seriously. The ministry will determine next steps after careful review of all claims."

When asked what billing issues the ministry is reviewing, and at what hospitals, Mr. Jensen replied, "The ministry doesn't publicly divulge which billings we may be investigating."

At Southlake, at least one doctor formally complained about Dr. Duic to Dr. Nancy Merrow, who was the hospital chief of staff in 2011. Dr. Merrow, currently chief of staff at Georgian Bay General Hospital, did not respond to a list of questions sent to her by The Globe.

Two others, Dr. Flindall and a third doctor, said they complained about Dr. Duic's leadership style to the subsequent chief of staff, Dr. Beatty. Neither felt their complaints went anywhere.

In fact, most of the doctors at Southlake took issue with Dr.

Duic soon after he arrived.

Within months of Dr. Duic taking over as chief, 14 doctors at Southlake signed an open letter to him. The letter described a meeting among the physicians in which "there emerged allegations against you that included bullying, coercion and intimidation of physicians occurring since your arrival at Southlake."

The letter continued: "Worried about their personal futures at Southlake, people described developing fear of expressing themselves openly at this point."

Several doctors interviewed think part of the reason Southlake administration hasn't acted on complaints is that Dr. Duic brings in significant money in performance bonuses, paid by the Ministry of Health. For 20172018, Southlake Hospital received $2.5-million based on how quickly patients are seen in emergency and how short their stay is.

"WE DO NOT TOLERATE DISCRIMINATION" Southlake has hired legal firm Rubin Thomlinson to lead the new investigation, which is looking into allegations relating to gender discrimination, bullying and harassment. Dr. Duic remains chief.

"At Southlake, we do not tolerate discrimination of any type and we take allegations of discrimination seriously," read a statement provided by Southlake's Ms. Perrier. "Physician billing is a matter between individual physicians and the Ministry of Health and Long-Term Care. We defer to the Ministry on this matter."

Dr. Lynn Wilson, vice-dean of partnerships at the University of Toronto's faculty of medicine, is encouraging Mr. Kastner's clients to come forward to the school with their concerns. U of T, where Dr. Duic is a faculty member, sends medical students and residents to Southlake emergency for training.

"Nearly all of the concerns raised regarding Dr. Duic relate to his behaviour in the clinical setting and fall within the hospitals' exclusive purview to investigate and address," Dr. Wilson wrote in response to questions from The Globe.

"To the extent those concerns touch on the supervision of our learners or relate to the educational environment, we reviewed all of Dr. Duic's MD Program and Post-MD Program teaching evaluations from 2006 to 2017, for any suggestion of gender discrimination or equity issues.

None was found."

As for the group of eight complainants, they say are relieved that an independent investigation is finally happening, but wish it hadn't taken so long.

Wendy Glauser is a Toronto-based freelance reporter who specializes in health care. She can be reached at wendyglauser@gmail.com.

Associated Graphic

One of the doctors who lodged a complaint against Dr. Marko Duic is pictured at her home. The group of eight women who launched the formal complaint chose to remain anonymous because they were worried about possible repercussions to their careers. GALIT RODAN/THE GLOBE AND MAIL

Dr. Duic, left, took over as emergency chief at Toronto's St. Joseph's Health Centre, above, in 2002. The emergency department was male-dominated when he arrived, and stayed that way under him. ABOVE: FRED LUM/THE GLOBE AND MAIL

Dr. Duic took over as emergency department chief at Southlake Regional Health Centre, above, in Newmarket, Ont., in 2011. Toronto-based lawyer Danny Kastner, left, has sent a letter to Southlake on behalf of eight doctors asking the hosptial to launch an independent investigation to examine alleged gender discrimination in both the hiring and training of doctors. ABOVE: FRED LUM/THE GLOBE AND MAIL; RIGHT: GALIT RODAN/ THE GLOBE AND MAIL